The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis

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The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
©Journal of Sports Science and Medicine (2021) 20, 535-545
http://www.jssm.org DOI: https://doi.org/10.52082/jssm.2021.535

` Review article

The Accumulated Effects of Foam Rolling Combined with Stretching on Range of
Motion and Physical Performance: A Systematic Review and Meta-Analysis

Andreas Konrad 1, Masatoshi Nakamura 2, Daniel Bernsteiner 1 and Markus Tilp 1
1
    Institute of Human Movement Science, Sport and Health, Graz University, Austria
2
    Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan

                                                                           shorter stretching durations (
The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
536                                                                                  Combined effects of foam rolling and stretching

(including all techniques) to that of stretching or foam roll-   of the references (search through the reference list) and ci-
ing alone on both ROM and physical performance. A fur-           tations (search through Google Scholar) of the nine already
ther goal was to distinguish between the effects of the          included papers, three more papers were identified as being
stretching technique (static stretching, dynamic stretching),    relevant. Therefore, in total, 12 papers were included in this
the type of foam rolling (vibration foam rolling, non-vibra-     systematic review and were used for the meta-analysis. The
tion foam rolling), the tested muscles (hamstrings, quadri-      whole search process is depicted in Figure 1.
ceps, triceps surae, hip, shoulder), and the order of the com-
bined treatment (either foam rolling followed by stretch-        Inclusion and exclusion criteria
ing, or vice versa) by the use of a subgroup analysis.           This review considered studies that compared the com-
                                                                 bined effects of an acute bout of both stretching and foam
Methods                                                          rolling on ROM and/or performance parameters (e.g.,
                                                                 strength, jump height) to the effects of foam rolling or
This review was conducted according to the PRISMA                stretching alone in healthy participants. We included stud-
guidelines and the suggestions from Moher et al. (2009) for      ies in the English, German, and Japanese languages with
systematic reviews with meta-analysis.                           crossover (pre- to post-comparison or post-comparison) or
                                                                 parallel group (pre- to post-comparison) designs. However,
Search strategy
                                                                 we excluded conference papers and theses.
An electronic literature search was performed in PubMed,
Scopus, and Web of Science. The search period ranged
from 1990 until the 15th February 2021. The keywords for         Extraction of the data
the online search were (“foam rolling” OR “self-myofas-          From the included papers, the characteristics of the partic-
cial release” OR “roller massage” OR “foam roller”) AND          ipants, the sample size, the study design, the characteristics
(stretch*), and they were the same for all the databases. The    of the intervention (e.g., stretching technique, vibration
systematic search was done by three independent research-        foam rolling vs. non-vibration foam rolling, duration), and
ers (AK, MN, DB). In the first step, all the hits were           the results of the main variables (ROM and/or performance
screened by their abstract. If the content of a study re-        parameters) were extracted. For the main variables, either
mained unclear, the full text was screened to identify the       the pre- and post-values (plus standard deviations) or the
relevant papers. Following this independent screening pro-       post-values (plus standard deviations) of the combined
cess, the researchers compared their findings. Disagree-         groups (stretching plus foam rolling) and the single inter-
ments were resolved by jointly reassessing the studies           vention groups (foam rolling or stretching, but also from
against the eligibility criteria. Overall, 169 papers were       the control group,) were extracted. If the required data were
screened, from which nine papers were found to be eligible       missing, the authors of the studies were contacted via
for this review. However, following the additional search        email.

         Figure 1. PRISMA flowchart.
The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
Konrad                                                                                                                                                                                     537

Statistics and data synthesis                                                                    In total, 12 studies compared the effects of a combined treatment (foam rolling plus
The meta-analysis was performed using Comprehensive Meta-Analysis software, accord-              stretching or stretching plus foam rolling) with the effects of stretching or foam rolling
ing to the recommendations of Borenstein et al. (2009). By the use of a random-effect            alone on ROM. Within these 12 studies, seven studies compared the effects of a combined
meta-analysis, we assessed the effect size of the ROM in terms of the standardized mean          treatment with stretching on performance parameters. Overall, 17 effect sizes could be
difference between the combined effects (foam rolling and stretching together) and               extracted for the ROM parameters and 24 for the performance parameters. In summary,
stretching alone, between the combined effects and foam rolling alone, and between the
combined effects and a control condition. Due to the smaller number of available studies         267 participants (143 males and 124 females) with a mean age of 22.9 (±5.1 years) partic-
for the performance parameters and the restriction that a minimum of three studies was           ipated in the included studies. Out of the 267 participants 141 were athletes, 76 were phys-
necessary to perform a meta-analysis, we could only assess the effect size of the combined       ically active, and six were sedentary. The activity level of the remaining 44 was not de-
effects, compared to stretching alone. Moreover, by using a mixed-effect model, we per-          fined. Table 1 presents the characteristics and outcomes of the 12 studies.
formed subgroup analyses with the stretching technique (static stretching, dynamic
stretching), the type of foam rolling (vibration foam rolling, non-vibration foam rolling),      Risk of bias assessment and methodological quality
the tested muscles (hamstrings, quadriceps, triceps surae, hip, shoulder), and the order of      The Egger’s regression intercept test indicated that no reporting bias was likely for the
the combined treatment (either foam rolling followed by stretching or stretching followed        meta-analysis dealing with ROM and for the comparison of the combined treatment with
by foam rolling) in both the analyses of the ROM and performance parameters. In addition,        stretching (intercept -0.59; P = 0.31), foam rolling (intercept 0.78; P = 0.81), or the control
for the performance parameters, we also performed a subgroup analysis for the type of            condition (intercept 0.32; P = 0.91). When comparing the effect on performance parame-
task (strength, jump height, sprinting). A minimum of two effect sizes per subgroup was          ters between the combined treatment and stretching alone, the Egger’s regression intercept
necessary to perform a subgroup analysis. To determine if there were differences between         test indicated a potential for reporting bias (intercept -1.51; P = 0.00). The average PEDro
the effect sizes of the subgroups, Q-statistics were applied (Borenstein et al., 2009). Ac-      score value is 6.92 (±1.31), indicating a low risk of bias (Maher et al., 2003; Moran et al.,
cording to the recommendations of Hopkins et al. (2009), we defined the effects for a            2021). The two assessors agreed for 125 out of the 132 criteria (12 studies × 11 scores).
standardized mean difference of 4.0 as triv-      The mismatched outcomes were discussed and the assessors finally agreed on the scores
ial, small, moderate, large, very large, and extremely large, respectively. I2 statistics were   presented in Table 2.
calculated to assess the heterogeneity among the included studies, and thresholds of 25%,
50%, and 75% were defined as having a low, moderate, and high level of heterogeneity,            Range of Motion
respectively (Behm et al., 2021b; Higgins et al., 2003). An alpha level of 0.05 was defined       Combined stretching/foam rolling vs. stretching alone
for the statistical significance of all the tests                                                 The meta-analysis with 17 effect sizes from 12 studies revealed no significant difference
                                                                                                 in ROM changes between the combined condition and the stretching condition alone (ES
Bias assessment and methodological quality                                                       = 0.032; Z = 0.517; CI (95%) -0.090 to 0.155; P = 0.61; I2 = 0.00) (see Figure 2). Fourteen
The methodological quality of the included studies was assessed using the PEDro scale.           out of the 17 effect sizes allowed us to calculate pre- to post-changes. The remaining three
In total, 11 methodological issues were assessed by two independent researchers (AK,             effect sizes were based on post-values only. The combined condition and the stretching
MN) and assigned with either one or no point. Hence, studies with a higher score represent       condition alone (pre- to post-comparison) showed an average increase in ROM of 6.83%
higher methodological quality. If any conflict between the ratings of the two researchers        (CI (95%) -0.34% to 14.00%) and 5.26% (CI (95%) -1.59% to 12.10%), respectively.
was found, the methodological issues were reassessed and discussed. Moreover, the Eg-            None of the subgroup analyses, including the stretching technique (static stretching,
ger’s regression intercept test was applied to detect possible publication bias.                 dynamic stretching) (Q = 0.01; P = 0.92), the type of foam rolling (vibration foam rolling,
                                                                                                 non-vibration foam rolling) (Q = 0.05; P = 0.83), and the order of the combined treatment
Results                                                                                          (Q = 0.66; P = 0.42), revealed significant differences in ROM. However, we did not
                                                                                                 perform a subgroup analysis with the tested muscles, since there were subgroups with only
Results of the search                                                                            one effect size.
The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
538                                                                                                                                                            Combined effects of foam rolling and stretching

Table 1. Characteristics of the included studies (n = 12).
                                                      Treatment                                                                                   Outcome
 Study Name           Participants                    Foam rolling                Stretching                                 Combined             Range of motion          Performance
                      N = 29; 8 male and 21                                       Dynamic stretching 20 min: Dynamic
                                                      3 x 30 s/MTU: gluteals,
                      female (23 physically ac-                                   movements of as large ROM as               Foam rolling +
 Smith, et al., 2018                                  hamstrings, quadriceps,                                                                     Sit and reach            Vertical jump height (cm)
                      tive/6 sedentary) (age 22 ± 3                               possible targeting gluteals, hamstrings,   dynamic stretching
                                                      and calf
                      years)                                                      quadriceps, and calf
                                                      20 s/MTU with vibration:
                      N = 40; 25 male and                                         Dynamic stretching: 8 dynamic              Dynamic stretching
                                                      quadriceps, hamstrings,                                                                   Knee flexion               CMJ height (cm)
 Lin et al., 2020     15 female college badminton                                 movements of the trunk + upper and         + vibration foam
                                                      calf, rotator cuff, lower                                                                 Knee extension             Agility (s)
                      players (age 21.4 ± 1.5 years)                              lower extremities                          rolling
                                                      back
                      N = 12; 12 male softball                                    Static stretching: 3 x 30 s per stretch:                        Glenohumeral
                                                      2 x 60 s/MTU:                                                          Foam rolling +
 Fairall et al., 2017 players (age 36.92 ± 11.17                                  sleeper stretch                                                 internal rotation                          -
                                                      infraspinatus                                                          static stretching
                      years)                                                      and cross-body stretch                                          ROM
                                                      30 s/MTU: hip flexors
                                                      and quadriceps, adduc-                                                                                               Squat jump height (cm)
                      N = 14; 14 female               tors,                       Dynamic stretching: For 5 min;                                                           CMJ height (cm)
 Richman et al.,                                                                                                             Foam rolling +
                      (8 volleyball, 6 basketball)    tensor fasciae latae and    participants performed their own rou-                           Sit and reach            Drop jump height (cm)
 2019                                                                                                                        dynamic stretching
                      players (age 19.8 ± 1.3 years) gluteus, hamstrings, plan-   tine                                                                                     Agility T-Test (s)
                                                      tar flexors, and dorsiflex-                                                                                            Short sprint (s)
                                                      ors
                      N = 11; 6 male and 5 female
 Škarabot et al.,                                                                 Static stretching: 3 x 30 s plantar        Foam rolling +
                      swimmers (age 15.3 ± 1.0        3 x 30 s plantar flexors                                                                    Dorsiflexion ROM          -
 2015                                                                             flexors                                    static stretching
                      years)
                                                                                                                                                                           CMJ height (inches)
                                                                                                                                                Hip flexion active
                      N = 12; 7 male and 5 female 30 s/MTU:                                                                  Static stretching                             Hurdle jump height (inches)
 Hodgson et al.,                                                                  Static stretching: 2 x 30 s/MTU                               Hip flexion passive
                      recreationally trained athletes hamstrings and quadri-                                                 (30 s/MTU) + foam                             Hurdle jump contact time (s)
 2019                                                                             hamstrings and quadriceps                                     Knee flexion active
                      (age range 18-30 years)         ceps                                                                   rolling (30 s/MTU)                            Knee flexion peak torque (Nm)
                                                                                                                                                Knee flexion passive
                                                                                                                                                                           Knee extension peak torque(Nm)
                      N = 24 male soccer players;    30 s/MTU:
                      11 in the control group (age   quadriceps,                  Static stretching: 10 s/MTU
 Kyranoudis et al.,                                                                                                          Foam rolling +                                CMJ height (cm)
                      21.7 ± 1.1 years); 13 in the   hamstrings,                  quadriceps, hamstrings,                                         Hip flexion ROM
 2019                                                                                                                        static stretching                             CMJ free height (cm)
                      experimental group (age 21.6   adductors,                   adductors, gastrocnemius
                      ± 0.7 years).                  gastrocnemius
                                                                                 Dynamic stretching: 4 x 15 repetitions                                                    Hamstring strength 60°/s (Nm)
                                                      4 x 30 s/MTU                                                           Dynamic stretching
 Che Hsiu et al.,     N = 10; 10 female handball                                 (5 x slow and 10 x as fast as possible)                        Knee extension             Hamstring strength 240°/s (Nm)
                                                      with vibration: quadriceps                                             + vibration foam
 2021                 players (age 21 ± 1 years)                                 targeting the quadriceps and hamstring                         Knee flexion               Quadriceps strength 60°/s (Nm)
                                                      and hamstrings                                                         rolling
                                                                                 muscles                                                                                   Quadriceps strength 240°/s (Nm)
                      N = 18; 18 female                                          Dynamic stretching: 60 s dynamic
                                                                                                                             Foam rolling +
 Cunha et al., 2021   recreationally trained athletes 60 s hamstrings            movements targeting the hamstring                                Straight leg raise        -
                                                                                                                             dynamic stretching
                      (age 24.0 ± 2.0 years)                                     muscles
The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
Konrad                                                                                                                                                                                     539

Table 1. Continues…
                                                     Treatment                                                                      Outcome
 Study Name             Participants                 Foam rolling           Stretching                         Combined             Range of motion      Performance
                        N = 44; 26 male (age 21.7
                        ± 1.7 years) and 18 female
                                                                                                               Foam rolling +
 Smith et al., 2019     athletes (age 21.3 ± 2.0     3 x 30 s calf          Static stretching: 3 x 30 s calf                        Ankle dorsiflexion   -
                                                                                                               static stretching
                        years); activity level not
                        reported
                                                     30 s/MTU:
                                                                            Dynamic stretching: dynamic                                                  Vertical jump height (cm)
                                                     thoracic/lumbar
                        N = 11; 11 male physically                          movements of the whole body                                                  Standing long jump (cm)
                                                     spine, gluteal, ham-                                      Foam rolling +
 Peacock et al., 2014   active individuals (age 22.2                        either                                                  Sit and reach        18.3 m pro agility (s) Indirect 1-RM
                                                     string,                                                   dynamic stretching
                        ± 2.2 years)                                        performed as 2 x 10                                                          bench press (kg)
                                                     calf, pectoral,
                                                                            repetitions or 2 x 10 m                                                      37 m sprint (s)
                                                     quadriceps
                        N = 42; 24 male and 18
                                                                            Dynamic stretching: 60 s in
                        female physical therapy                                                                Foam rolling +
 Somers et al., 2020                                 60 s calf              downward dog targeting the                              Ankle dorsiflexion   -
                        students (age 26.1 ± 4.0                                                               dynamic stretching
                                                                            posterior chain
                        years)

  Table 2. PEDro scale of the included studies; * = was not counted for the final score; 1 = one point awarded; 0 = no point awarded.
                                  Inclusion Random Concealed Similarity               Subject Therapist Assessor         >85%      Intention to Between-group Point estimates
                                                                                                                                                                                      Total
                                   criteria allocation allocation at baseline blinding blinding blinding follow-up treat analysis                comparison   and variability
   Smith et al., 2018                 1            1           0            1             0          0          0           1           1             1              1                  6
   Lin et al., 2020                   1            1           0            1             0          0          0           1           1             1              1                  6
   Fairall et al., 2017               1            1           0            1             0          0          0           1           1             1              1                  6
   Richman et al., 2019               1            1           0            1             0          0          0           1           1             1              1                  6
   Škarabot et al., 2015              1            1           1            1             0          0          0           1           1             1              1                  7
   Hodgson et al., 2019               1            1           1            1             0          0          0           1           1             1              1                  7
   Kyranoudis et al., 2019            1            1           0            1             0          0          0           1           1             1              1                  6
   Che Hsiu et al., 2021              1            1           0            1             0          0          0           1           1             1              1                  6
   Somers et al., 2020                1            1           1            1             0          1          1           1           1             1              1                  9
   Smith et al., 2019                 1            1           1            1             0          1          1           1           1             1              1                  9
   Peacock et al., 2014               1            1           0            1             0          0          0           1           1             1              1                  6
   Cunha et al., 2021                 1            1           1            1             0          1          1           1           1             1              1                  9
The Accumulated Effects of Foam Rolling Combined with Stretching on Range of Motion and Physical Performance: A Systematic Review and Meta-Analysis
540                                                                                           Combined effects of foam rolling and stretching

Figure 2. Forest plot presenting the combined effects compared to stretching on range of motion. (Std diff in means = stand-
ardized difference in means; CI = confidence interval).

Figure 3. Forest plot presenting the combined effects compared to foam rolling on range of motion. (Std diff in means = stand-
ardized difference in means; CI = confidence interval; FR= foam rolling).

Combined stretching/foam rolling vs. foam rolling                          foam rolling studies and studies where stretching was fol-
alone                                                                      lowed by foam rolling were part of this meta-analysis.
The meta-analysis with six effect sizes from six studies re-               However, we did not perform a subgroup analysis with the
vealed no significant difference in ROM changes when the                   tested muscles since there were subgroups with only one
combined condition was compared to the foam rolling con-                   effect size.
dition alone (ES = -0.225; Z = -1.182; CI (95%) -0.597 to
0.148; p = 0.24; I2 = 62.89) (see Figure 3). The combined                  Combined stretching/foam rolling vs. control condition
condition and foam rolling condition alone (pre- to post-                  The meta-analysis with six effect sizes from three studies
comparison) showed an average increase in ROM of                           revealed a significantly higher increase of a small magni-
13.77% (CI (95%) -0.61% to 28.16%) and 7.19% (CI                           tude in ROM in the combined condition compared to the
(95%) 2.48% to 11.89%), respectively.                                      control condition without any intervention (ES = -0.332; Z
        The subgroup analyses differentiating between dif-                 = -2.499; CI (95%) -0.593 to -0.072; p = 0.012; I2 = 32.38)
ferent stretching techniques revealed no significant differ-               (see Figure 4). The six effect sizes of the combined condi-
ence in ROM (Q = 0.58; p = 0.45). A subgroup analysis                      tion and the control condition (pre- to post-comparison)
including the type of foam rolling or the order of the com-                showed an average change of 1.51% (CI (95%) -4.74% to
bined treatment was not possible since only non-vibration                  7.76%) and 0.21% (CI (95%) -1.16% to 1.59%), respect-

Received: 18 June 2021 / Accepted: 21 June 2021 / Published (online): 01 July 2021
Konrad et al.                                                                                                             541

tively. The subgroup analyses of the stretching technique       one effect size.
(Q = 0.78; p = 0.38), the tested muscles (Q = 1.44; p =
0.49), and the order of the combined treatment (Q = 0.78;       Discussion
p = 0.38) revealed no significant difference in ROM
                                                                The purpose of this review was to compare the effects of
changes. A subgroup analysis with the type of foam rolling
                                                                an acute bout of a combined treatment of stretching and
was not possible since only non-vibration foam rolling
                                                                foam rolling to the effects of stretching or foam rolling
studies were part of this meta-analysis.
                                                                alone on both ROM and performance parameters in healthy
                                                                subjects. For ROM, the meta-analysis revealed the superior
Performance                                                     effect of a combined treatment compared to the control
A meta-analysis of the effects on performance was only          condition (no stretching or foam rolling); however, no su-
possible with the combined condition and the stretching         perior effect was found for the combined treatment com-
condition alone since there were insufficient studies and       pared to either stretching or foam rolling alone. In addition,
effect sizes for the foam rolling condition available.          further subgroup analyses of ROM (e.g., stretching tech-
        The meta-analysis with 24 effect sizes from seven       nique, muscle groups tested) showed no differences be-
studies revealed no significant difference in performance       tween the modalities. With regard to performance, the
parameters between the combined condition and the               meta-analysis revealed no difference between the com-
stretching condition alone (ES = -0.029; Z = -0.503; CI         bined treatment compared to stretching or foam rolling
(95%) -0.142 to 0.084; p = 0.62; I2 = 0.00) (see Figure 5).     alone; however, the subgroup analysis of performance re-
Ten out of the 24 effect sizes allowed us to calculate pre-     vealed the trivial but superior effect of the combined treat-
to post-changes. The remaining 14 effect sizes were based       ment compared to stretching alone, but only if the foam
on post-values only. The combined condition and stretch-        rolling was followed by stretching.
ing condition alone (pre- to post-comparison) showed            Three meta-analyses were performed for ROM. Thereby,
changes in performance of -0.41% (CI (95%) -3.02% to            the combined effects (stretching and foam rolling) were
2.19%) and -0.07% (CI (95%) -3.34% to 3.22%), respec-           compared to a control condition, stretching alone, and foam
tively.                                                         rolling alone. The combined treatment had a superior effect
        By comparing the order of the combined treatment        on ROM compared to the control condition. Increases in
(either foam rolling followed by stretching or vice versa),     ROM following a single stretching (Behm et al., 2016;
the subgroup analysis revealed a significant difference be-     Behm et al., 2021a; Behm and Chaouachi, 2011) or foam
tween the subgroups of “foam rolling followed by stretch-       rolling treatment (Wilke et al., 2020) were reported by sev-
ing vs. stretching alone” and “stretching followed by foam      eral studies. However, it is not clear if the increases in
rolling vs. stretching alone” (Q = 5.53; p = 0.02). While       ROM have an accumulated effect when foam rolling and
stretching followed by foam rolling showed a similar mag-       stretching are performed within one training session, com-
nitude of change as stretching alone (ES = 0.10; p = 0.21),     pared to foam rolling or stretching alone. Anderson et al.
the foam rolling followed by stretching exercise revealed a     (2021) reported in their review only a small additional ef-
significant but trivial better effect than stretching alone     fect when comparing a combined treatment with foam roll-
(ES= -0.17; p = 0.04) (see Figure 5). Moreover, further         ing and dynamic stretching to dynamic stretching alone.
subgroup analyses of the stretching technique (Q = 0.11; p      However, the authors did not perform a meta-analysis or
= 0.74), the type of foam rolling (Q = 3.21; P = 0.07), and     include the static stretching technique, or consider other
the type of task (strength, jump height, sprinting) (Q =        muscles than the hamstrings. Our meta-analysis included
0.82; p = 0.66) revealed no significant difference in perfor-   static stretching and different muscles, but neither showed
mance. However, we did not perform a subgroup analysis          any superior effect for a combined treatment compared to
of the tested muscles since there were subgroups with only      stretching alone or foam rolling alone.

Figure 4. Forest plot presenting the combined effects compared control condition on range of motion. (Std diff in means =
standardized difference in means; CI = confidence interval).
542                                                                                 Combined effects of foam rolling and stretching

Figure 5. Forest plot presenting the combined effects compared to stretching on performance parameters, including a subgroup
analysis with the order of the combined treatment (Std diff in means = standardized difference in means; CI = confidence
interval; FR= foam rolling).

We would have expected that a change in tissue compli-           Wilke et al. (2020) reported in a recent meta-analysis that
ance (e.g., muscle or tendon stiffness), which has been re-      foam rolling and stretching have a similar magnitude of
ported following an acute bout of stretching (Kato et al.,       change on ROM, so that athletes could apply either stretch-
2010; Kay et al., 2015; Konrad et al., 2017), and the addi-      ing or foam rolling to increase ROM, according to their
tional changes in stretch or pain tolerance following foam       preference. However, several studies have reported en-
rolling (Nakamura et al., 2021), might have led to greater       hanced recovery and reduced delayed-onset muscle sore-
gains in ROM compared to stretching or foam rolling              ness (DOMS) following foam rolling (MacDonald et al.,
alone. However, this was not observed in this meta-analy-        2014; Nakamura et al., 2020; Pearcey et al., 2015), but not
sis. A possible reason for the lack of an additional effect in   following a stretching exercise (Afonso et al., 2021;
the combined treatment might be a saturation effect for          Henschke 2011). Therefore, if a secondary goal is to reduce
ROM, which has also been observed following a certain            DOMS, besides the increase in ROM, foam rolling is likely
duration of stretching (Mizuno, 2019) and foam rolling           the better treatment.
(Nakamura et al., 2021). Mizuno (2019) reported a similar                With regard to the effects on performance parame-
amount of increase in ROM when comparing 10 s of static          ters, due to the lack of studies and effect sizes, a compari-
stretching with 100 s. Moreover, Nakamura et al. (2021)          son was only possible between the combined treatment and
reported no further changes in ROM following a single            a stretching treatment alone (but not foam rolling or a
foam rolling treatment applied for 300 s compared to 90 s.       control condition). The meta-analysis revealed no signifi-
Hence, if the single treatment of stretching or foam rolling     cant changes between the combined treatment and stretch-
exceeds a certain duration, no additional changes in ROM         ing alone. This is in contrast to the review by Anderson et
can be expected. The duration range of the combined treat-       al. (2021), who concluded that foam rolling and dynamic
ment of the included studies when foam rolling was com-          stretching might have a superior effect compared to dy-
bined with static stretching was between 40 s and 210 s          namic stretching alone. The authors reported that two out
(mean: 134.0 ± 77.9 s). Hence, the assumed saturation fol-       of four studies found a greater increase in vertical jump
lowing a combined treatment for ROM is not unlikely. Ac-         height compared to dynamic stretching alone. Moreover,
cording to the results of our meta-analysis, it can be recom-    two out of three studies included in their review reported a
mended that foam rolling (with a duration range between          greater effect on agility following a combined treatment
30 s and 120 s; mean 66.0 ± 36.9 s) or stretching (with a        (foam rolling and dynamic stretching) compared to dy-
duration range between 10 s and 90 s; mean 65.7 ± 28.8 s)        namic stretching alone. However, Anderson et al. (2021)
could be performed to increase the ROM of a joint acutely,       only included studies with dynamic stretching and studies
rather than a more time-consuming combined treatment             assessing ROM with a sit and reach test. Consequently,
This goes in line with previous recommendations on foam          several studies that investigated the combined effects on
rolling (Behm et al., 2020) or stretching (Behm, 2018).          performance parameters with other stretching techniques
Konrad et al.                                                                                                                                   543

and other muscles were excluded. In the present meta-anal-               the country in which they were performed. The authors have no conflict
                                                                         of interest to declare. The datasets generated during and/or analyzed dur-
ysis, we analyzed 12 studies in total, including seven stud-             ing the current study are not publicly available, but are available from the
ies of dynamic stretching and five of static stretching. Sev-            corresponding author who was an organizer of the study.
eral reviews reported major differences in the effects be-
tween static and dynamic stretching if applied prior to a                References
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dency of improvement (P = 0.06) in sprint performance                    Amiri-Khorasani, M., Abu Osman, N. A. and Yusof, A. (2011) Acute
(+0.7%), but negligible effects on jump or strength perfor-                      effect of static anddynamic stretching on hip dynamic range of
mance. This is in accordance with another review                                 motion during instep kicking in professional soccer players.
                                                                                 Journal of Strength and Conditioning Research, 25(6), 1647-
(Cheatham et al., 2015) that reported that a single bout of a                    1652. https://doi.org/10.1519/JSC.0b013e3181db9f41
foam rolling exercise likely does not induce changes in per-             Anderson, B. L., Harter, R. A. and Farnsworth, J. L. (2021) The Acute
formance parameters. Therefore, similar to the results of                        Effects of Foam Rolling and Dynamic Stretching on Athletic
Anderson et al. (2021), we expect that a combination of a                        Performance: A Critically Appraised Topic. Journal of Sport
                                                                                 Rehabilitation 30(3), 501-506. https://doi.org/10.1123/JSR.2020-
foam rolling and dynamic stretching treatment will likely                        0059
lead to a greater increase in performance than dynamic                   Behm, D. G., Kay, A. D., Trajano, G. S. and Blazevich, A. J. (2021a)
stretching alone. However, our subgroup analysis of the                          Mechanisms underlying performance impairments following
different stretching techniques (static stretching, dynamic                      prolonged static stretching without a comprehensive warm-up.
                                                                                 European Journal of Applied Physiology 121, 67-94.
stretching) did not reveal a significant effect of the com-                      https://doi.org/10.1007/s00421-020-04538-8
bined treatment including dynamic stretching compared to                 Behm, D. G., Alizadeh, S., Anvar, S. H., Drury, B., Granacher, U. and
dynamic stretching alone. Hence, according to our meta-                          Moran, J. (2021b) Non-local Acute Passive Stretching Effects on
analysis, dynamic stretching alone can lead to a similar per-                    Range of Motion in Healthy Adults: A Systematic Review with
                                                                                 Meta-analysis. Sports Medicine 51, 945-959.
formance changes as the combined treatment. Therefore,                           https://doi.org/10.1007/s40279-020-01422-5
foam rolling does not necessarily have to be included if the             Behm, D. G., Alizadeh, S., Hadjizadeh Anvar, S., Mahmoud, M. M. I.,
goal is to increase performance. Similar to the results for                      Ramsay, E., Hanlon, C. and Cheatham, S. (2020) Foam Rolling
the dynamic stretching group, no difference between the                          Prescription: A Clinical Commentary. Journal of Strength and
                                                                                 Conditioning Research 34, 3301-3308.
combined treatment and the static stretching treatment                           https://doi.org/10.1519/JSC.0000000000003765
alone was shown by the meta-analysis.                                    Behm, D. G., Blazevich, A. J., Kay, A. D. and McHugh, M. (2016) Acute
        Further subgroup analyses showed no significant                            effects of muscle stretching on physical performance, range of
differences between the different muscles tested (e.g.,                            motion, and injury incidence in healthy active individuals: a
                                                                                   systematic review. Applied Physiology, Nutrition, and
quadriceps, hamstrings), the type of foam rolling (vibration                       Metabolism 41(1), 1-11.
foam rolling, non-vibration foam rolling), or the type of                        https://doi.org/10.1139/apnm-2015-0235
task (e.g., strength, power). However, a significant differ-             Behm, D. G. and Chaouachi, A. (2011) A review of the acute effects of
ence could be detected between the orders of the combined                        static and dynamic stretching on performance. European Journal
                                                                                 of Applied Physiology 111(11), 2633-2651.
treatment. Stretching followed by foam rolling showed a                          https://doi.org/10.1007/s00421-011-1879-2
similar magnitude of change on performance as stretching                 Behm, D. G. (2018) Recommendations for stretching prescription. In The
alone; however, the foam rolling followed by stretching ex-                      Science and Physiology of Flexibility and Stretching. Routledge.
ercise revealed a significantly but trivial better effect than                   https://doi.org/10.4324/9781315110745-6
                                                                         Borenstein, M., Hedges, L. V, Higgins, J. P. T. and Rothstein, H. R.
stretching alone (see Figure 5). A possible mechanism for                        (2009) Introduction to Meta-Analysis.
why foam rolling before stretching can lead to a favorable                       https://doi.org/10.1002/9780470743386
effect compared to stretching alone is unclear and should                Che Hsiu, C., Chiu, C.H., Tseng, W.C., Ye, X., Chen, C.H., Wu, C.Y. and
be investigated in future studies.                                               Chang, C.K. (2021) Acute Effects of Combining Dynamic
                                                                                 Stretching and Vibration Foam Rolling Warm-up on Lower-Limb
                                                                                 Muscle Performance and Functions in Female Handball Players.
Conclusion                                                                       The Journal of Strength and Conditioning Research.
                                                                                 https://doi.org/10.1519/JSC.0000000000003998
It can be concluded that athletes under time constraints do              Cheatham, S. W., Kolber, M. J., Cain, M. and Lee, M. (2015) The effects
                                                                                 of self‐myofascial release using a foam roll or roller massager on
not have to combine stretching with foam rolling in order                        joint range of motion, muscle recovery, and performance: a
to increase their ROM because the combination does not                           systematic review. International Journal of Sports Physical
lead to any additional effects. However, if the goal is to                       Therapy 10(6), 827-838.
also increase performance (e.g., strength, speed), the com-              Cunha, J. C. O. M. de, Monteiro, E. R., Fiuza, A., Neto, V. G. C., Araujo,
                                                                                 G. S., Telles, L. G. S. and Novaes, J. S. (2021) Acute Effect of
bination of foam rolling followed by stretching (but not                         Foam Rolling Before Dynamic Stretching on the Active Hip
vice versa) should be favored compared to stretching alone.                      Flexion Range-of-Motion in Healthy Subjects. Journal of
                                                                                 Exercise Physiology Online 24(2), 81-90.
Acknowledgements                                                         Fairall, R. R., Cabell, L., Boergers, R. J. and Battaglia, F. (2017) Acute
This study was supported by a grant (Project J 4484) from the Austrian           effects of self-myofascial release and stretching in overhead
Science Fund (FWF). The experiments comply with the current laws of              athletes with GIRD. Journal of Bodywork and Movement
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                                                             AUTHOR BIOGRAPHY
 Key points                                                                Andreas KONRAD
                                                                           Employment
   This is the first meta-analysis to have compared the                   Institute of Human Movement Science,
    combined effects of foam rolling and stretching with                   Sport and Health, University of Graz
    the effects of stretching or foam rolling alone.                       Degree
                                                                           PhD, MSc, BSc
   The meta-analysis revealed a significant overall ef-                   Research interests
    fect on ROM of the combined treatment when com-                        Biomechanics, muscle performance,
    pared to no intervention.                                              training science, muscle-tendon-unit,
   The results showed no favorable effect on ROM or                       soccer science
    performance when compared to the effect of stretch-                    E-mail: andreas.konrad@uni-graz.at
    ing or foam rolling alone.                                             Masatoshi NAKAMURA
   The subgroup analysis revealed that, if the goal is to                 Employment
                                                                           Lecture, Institute for Human Movement
    increase performance, the combination of foam roll-
                                                                           and Medical Sciences, Niigata University
    ing followed by stretching (but not vice versa)                        of Health and Welfare, Niigata, Niigata,
    should be favored compared to stretching alone.                        Japan
                                                                           Degree
                                                                           PhD
                                                                           Research interests
                                                                           Physical therapy, stretching, exercise
                                                                           physiology, flexibility
                                                                           E-mail:
                                                                           masatoshi-nakamura@nuhw.ac.jp
                                                                           Daniel BERNSTEINER
                                                                           Employment
                                                                           Institute of Human Movement Science,
                                                                           Sport and Health, University of Graz
                                                                           Degree
                                                                           BSc
                                                                           Research interests
                                                                           Training science, biomechanics
                                                                           E-mail:
                                                                           daniel.bernsteiner@edu.uni-graz.at
                                                                           Markus TILP
                                                                           Employment
                                                                           Institute of Human Movement Science,
                                                                           Sport and Health, University of Graz
                                                                           Degree
                                                                           PhD
                                                                           Research interests
                                                                           Biomechanics, training science, muscle-
                                                                           tendon-unit, sports game analysis
                                                                           E-mail: markus.tilp@uni-graz.at

                                                              Mag. Dr. Andreas Konrad, BSc MSc
                                                             Institute of Human Movement Science, Sport and Health, Univer-
                                                             sity of Graz, Mozartgasse 14, A-8010 Graz, Austria
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